Mesh Complication Rates Following Pelvic Radiation Therapy in Women With History of Synthetic Midurethral Sling Implantation.

OBJECTIVE: To estimate the risk of mesh complications in women with and without subsequent pelvic and abdominal radiation therapy (RT). METHODS: We identified women within a large health care organization who underwent mesh-augmented surgery for pelvic floor disorders between 2008 and 2014 and subsequently received RT prior to 2018. We compared them to a randomly selected group of women who underwent similar mesh-augmented pelvic reconstructive surgery without RT in a 1:4 ratio. Mesh complications were identified through chart review corroborated with the ninth and tenth revisions of the International Classification of Diseases and Current Procedural Terminology codes for mesh complications. Mesh complications between groups were compared using survival analysis and Cox proportional hazards models. RESULTS: We identified 36 women with RT and compared them with 144 women without RT. Indications for mesh implantation and concomitant vaginal procedures were similar between the groups. The majority of mesh implants (94.4%) were midurethral slings. Twelve mesh complications (6.7%) were identified, with similar rates in the RT (8.3%) and no-RT (6.2%) groups (P = 0.65). The risk of mesh complications did not differ between groups when compared using the Cox proportional hazards model, controlling for age, body mass index, diabetes, menopausal status, and smoking (hazard ratio, 1.19; 95% confidence interval, 0.802-1.787). CONCLUSIONS: There was no difference in the occurrence of mesh-related complications between women with and without RT. Abdominopelvic RT may not substantially increase the risk of mesh complications following placement of a synthetic sling for stress urinary incontinence. The need for future RT may only be a minor factor in counseling patients on the risks of mesh implants for pelvic floor disorders.

Rehabilitation and reintegration programming adjunct to female genital fistula surgery: A systematic scoping review.

BACKGROUND: Female genital fistula is associated with significant physical, psychological, and economic consequences; however, a knowledge and practice gap exists around services adjunct to fistula surgery. OBJECTIVES: To examine rehabilitation and reintegration services provided adjunct to genital fistula surgery, map existing programming and outcomes, and identify areas for additional research. SEARCH STRATEGY: We searched the published and grey literature from January 2000 to June 2019. Two reviewers screened articles and extracted data using standardized methods. SELECTION CRITERIA: Research and programmatic articles describing service provision in addition to female genital fistula surgery were included. DATA COLLECTION AND ANALYSIS: Of 3047 published articles and 2623 unpublished documents identified, 26 and 55, respectively, were analyzed. MAIN RESULTS: Programming identified included combinations of health education, physical therapy, social support, psychosocial counseling, and economic empowerment, largely in sub-Saharan Africa. Improvements were noted in physical and psychosocial health. CONCLUSIONS: Existing literature supports holistic fistula care through adjunct reintegration programming. Improving the evidence base requires implementing robust study designs, increasing reporting detail, and standardizing outcomes across studies. Increased financing for holistic fistula care is critical for developing and supporting programming to ensure positive outcomes.

A Clinical Risk Model to Predict Obstetric Anal Sphincter Injuries in Laboring Patients.

OBJECTIVE: Our objective was to develop a risk stratification tool for predicting obstetric anal sphincter injury risk in women during labor. METHODS: In this retrospective cohort study of singleton deliveries within Kaiser Permanente Northern California, a predictive model for anal sphincter injury was developed within the 2013 birth cohort and validated in the 2014 birth cohort of 22,741 births. Predictors of obstetric anal sphincter injury were identified using multiple regression analysis and used to create a risk calculator tool based on effect size and clinical judgment. RESULTS: Duration of second stage of labor, vacuum delivery, history of anal sphincter injury, maternal and gestational ages, and maternal race and ethnicity were associated with elevated risk of anal sphincter injury. Using these risk factors, we developed a validated parity-stratified scoring system. Among nulliparous women, 116 (1.3%) had a score of zero, corresponding to a 0.9% risk, and 1024 (11.7%) had a score higher than 6, corresponding to a 27.5% risk of anal sphincter injury. Among the multiparous women, 1181 (8.4%) had a score of zero, corresponding to a 0.1% risk, and the 260 (1.9%) with a score higher than 10 had a 7.7% risk. The predictive ability of the score derived based on the 2013 data was applied to the 2014 data, and results showed that the predictive abilities were statistically similar, except for one subgroup: multiparous women with a total score of ≥10. CONCLUSIONS: Our anal sphincter injury risk stratification tool effectively predicts individual risk and can inform clinician and patient decision making to minimize maternal birth trauma.

Rehabilitation and reintegration programming adjunct to female genital fistula surgery: a scoping review protocol.

INTRODUCTION: Female genital fistula is a debilitating traumatic injury, largely birth-associated, globally affecting up to 2 million women, mostly in sub-Saharan Africa. Fistula has significant physical, psychological and economic consequences. Women often face challenges in reintegrating and resuming prior roles despite successful surgery. Synthesising the evidence on services adjunct to fistula surgery and their outcomes is important for developing the evidence base for best practices and identifying research priorities. This scoping review seeks to examine the range of rehabilitation and reintegration services provided as adjunct to genital fistula surgery, map the existing programming and outcomes, and identify areas for additional research. METHODS AND ANALYSIS: Our scoping review is informed by existing methodological frameworks and will be conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-ScR guidelines. The search strategy will be applied to nine biomedical, public health and social science databases. The initial search was completed on 27 September 2018. Grey literature will be identified through targeted Google searches and from organisational websites identified as relevant by the United Nations Population Fund (UNFPA) Campaign to End Fistula. We will iteratively build our search strategy through term harvesting and review, and search reference lists of reports and articles to identify additional studies. Two reviewers will independently screen titles and abstracts, followed by full-text screening of all potentially relevant articles and standardised data extraction. Articles eligible for inclusion will discuss research or programmatic efforts around service provision in adjunct to surgery among females with genital fistula. Data will be presented in summary tables accompanied by narrative description. ETHICS AND DISSEMINATION: Ethics approval is not required for a scoping review. Our results can be used to inform policy, serve as support for funding and development of reintegration programmes and highlight areas for subsequent research. Results will be disseminated at relevant conferences and published in a peer-reviewed journal.

Advances in pharmacotherapy for the treatment of overactive bladder.

PURPOSE OF REVIEW: To present the current literature on the pharmacologic management of overactive bladder, including combination therapies, agents still in clinical development, and special considerations related to individuals with cognitive decline, frailty and cardiovascular risk. RECENT FINDINGS: Combination therapy is shown to be more effective than monotherapy, without additional side effects. Preliminary studies on novel treatment methods, including new medications, as well was novel use of established medications, demonstrates improved efficacy with a favorable side effect profile. Investigation into new target pathways may be an area for future pharmacologic development. Special consideration should be given when prescribing anti-muscarinic medication in the frail adult population. Overactive bladder has been associated with frailty and anti-muscarinic medications have been associated with the worsening cognitive decline. SUMMARY: Combination therapy is a safe and effective alternative to patients with refractory overactive bladder. Caution should be taken in prescribing medications for the frail older adult, and alternative first- and third-line treatments should be considered. Future studies should involve long term data on safety and outcomes stratified by age with objective measurements of cognition and frailty.